Background: Aging is associated with both physical impairment and functional disability. One of the areas of concerns is a derangement in the activities of daily living (ADL) where the elderly people are unable to perform their basic personal care tasks. The present study was planned with the aim to evaluate functional impairment among rural elderly using ADL scale. Materials and Methods: The study was conducted as a cross-sectional population-based survey using multistage randomized sampling technique from August 2015 to October 2015 in Miran Sahib Health Zone of R S Pura health block in Jammu District in North-West India. The study involved 418 elderly individuals above 60 years of age. Results: A higher proportion of elderly (378/418; 90.43%) were classified as functionally independent. Among the study participants 9.54% (40/418) were found to have some had some impairment. Among the elderly impaired individuals, 5.26% (22/418) were moderately impaired while 2.64% (11/418) were severely impaired. However, importantly only a small proportion (7/418; 1.67%) of elderly individuals was completely dependent on others. Conclusion: The total impairment prevalence reported among the geriatrics in the current study was 9.5%. With the increase in the geriatric population expected in near future, this number will be significant. Policies with a clear focus on geriatric health-care need to be developed to reduce the dependency among elderly.

By 2025, the number of elderly people in the world is likely to touch 1.2 billion and 840 million of them would be in low-income countries.[1] The 2011 census of India reported that 8% of the total population comprised elderly people, and this figure is likely to touch 12.4% by 2026.[2]

Aging is associated with physical impairment and functional disability. The areas of more concern in terms of disability remains with activities of daily living (ADL) where the elderly people are unable to perform their basic personal care tasks.

With the increase in average life expectancy, the prevalence of chronic diseases has increased. With this, there is a growing recognition of human functions in health and illness.[3] Evidence has shown that older people have an increased risk of multiple comorbidities leading to a higher rate of disability among them.[4] Aging process per se and the health problems in elderly frequently present as decline in the functional status.

Functional assessment is one of the best ways to evaluate the health status of the elderly which provides objective data that may indicate further decline or improvement in the health status allowing room for appropriate interventions. An extensive search on PubMed revealed a paucity of data on the disability among the elderly people in this part of India. It was in this context, therefore, a study was undertaken with the aim to assess the functional status of the geriatric population using Katz basic ADL scale.[5]

Materials and Methods

The study was conducted as a cross-sectional population-based survey using multistage randomized sampling technique. The survey was conducted in Miran Sahib Health Zone of R S Pura health block in Jammu district of North-West India from August 2015 to October 2015, involving 418 elderly individuals above 60 years of age.

Background of study area

RS Pura block is located in the South West of Jammu City, adjacent to the Indo-Pak border, with a total area of 273 km2 and average density of 658/km2. There are 176 villages and one town (RS Pura town) in the block, with an estimated population of 1, 79,636. The health block RS Pura has been divided into 8 health zones administratively.

Methodology

In the first stage of the study, one of the health zones out of the eight health zones was selected by simple random sampling using lottery method of sampling. Each zone of the block was assigned a unique number. The numbers were then thoroughly mixed by putting them in a jar. Then, without looking, one of the numbers was selected. The zone thus selected was identified as the study area for carrying out this cross-sectional survey. Therefore, Miran Sahib Health Zone was identified for the conduct of this study. The Miran Sahib Health Zone caters to a population of 24,811 spread over 24 villages. Assuming a prevalence of functional impairment among elderly at 5% with a target population of around 24,811 from the study area, required sample size calculated was 284 at 99.9% confidence interval, design effect of 1 and allowable error of 5% using Epi Info Software (Stat-Cal-sample size and power, CDC, GA, USA).

In the second stage of sampling, the 24 villages of Miran Sahib Zone were divided into two groups. Group 1 villages were the villages within 2 km distance of Miran Sahib Health facility whereas as Group 2 villages were identified as villages more than 2 km distance from the health facility. One village each from the two groups from all four directions (with health facility in the center) was randomly chosen to complete a total of eight villages using lottery method of simple random technique. Each of the 24 villages was assigned a unique number after identification of their direction and assignment to each group. The contribution of each direction in terms of villages was; North: 4, South: 6; East: 8; and West: 6. The numbers of each direction were then thoroughly mixed by putting them in individual bowls (4 bowls). Then, without looking, 2 villages were selected from each bowl totaling 8 villages.

The sample size of 284 was targeted to be completed in these 8 villages with each village contributing a minimum of 36 elderly individuals (more than 60 years of age). However, a large survey population for inclusion in the survey was identified, with each village contributing a minimum of 50 individuals. Initially, only one elderly individual from one household was included in the study using Kish method. When creating the grid Kish, it was intended to select elderly persons within the household with equal probability. If the required sample of 50 individuals could not be met with, then the other elderly individuals of the household were included in this study.

A total of 418 individuals completed the study.

The first house was selected from within each selected village by simple random sampling using a random starting point after standing in the middle of the village. Starting from that house, all the eligible people more than 60 years of age were screened from the consecutive houses till a sample size of at least 50 was reached in that village. Participants having any acute illness like fever were excluded from the study. This was done avoid including elderly with functional disability due to acute illness.

The study protocol was approved by Institutes Ethics Committee. The procedure was explained to the participants at least a day before the study and informed written consent was obtained from each. Those who were not willing to participate were excluded from the study.

Functional disability was assessed by person's ability to perform the ADL in the six basic personal care tasks such as bathing, dressing, toileting, transferring, continence, and feeding. Each of these activities was given one point if a person was able to do the activity independently and zero point if doing the activity under supervision. A person with a score of six was consider as completely independent, Score 3–4 as having a moderate impairment, 2 or less as severe impairment with total score zero as completely dependent. The data thus collected was tabulated and expressed in percentages. Chi-square test was used for defining statistical significance.

Results

The majority (64.59%) of elderly population was in the age group of 60–69 years and only 15.1% of people were aged 75 years and above. The total number of geriatrics decreased as the age group advanced [Figure 1]. As depicted in [Figure 2], the majority of study population belonged to middle and lower middle class, i.e., 78.7% and least in upper middle class (6.94%). Out of total 418 elderly studied, the proportion of elderly females (aged ≥60 years), were higher (54.31%) than males (45.69%). A higher percent (71.29%) of elderly was married while 24.4% were widow/widower [Table 1]. A higher proportion of elderly (90.43%) were having no impairment of functional status while 9.54% were having some impairment. Among the functionally impaired individuals, 5.26% were moderately impaired whereas 2.64% were severely impaired. However, a small proportion (1.67%) of them was completely dependent [Table 2].

Assessment of chronic diseases and its association with functional impairment will help in the implementation of various preventive programs such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke and National Programme for Health Care of the Elderly which can reduce the disease burden among the elderly population in the country.

The total prevalence of functional impairment reported among the geriatrics in the current study was 9.5%. Given the expected increase in geriatric population in near future, this percentage is significant in terms of sheer numbers. The results of our study are in agreement with those reported by Konjengbam et al.[6] and Nugegoda and Balasuriya[7] who reported 12.2% and 10.3% prevalence, respectively. However, Fuchs et al. reported a higher prevalence but the study population comprised mainly of the oldest old.[8] Further studies conducted by the authors from West Bengal also report of a higher prevalence. Chakrabarty et al.[9] in his study in rural West Bengal reported 16.16% of the elderly to be functionally disabled while Biswas et al. reported 19.6% of the elderly impaired in ADL.[10]

Both these authors have reported substantially higher functional disability. These studies, as also our study, point to a significant proportion of elderly with a functional disability; a cause for concern for health-care givers.

The fact that total dependence in our study was the least among functionally impaired is a bright spot on otherwise gloomy sky although this could partly be attributed to a lower number of elderly in higher age groups finding a place in this study. In a study conducted by Biswas et al. 4.57% elderly reported with severe impairment in ADL's. This proportion is higher than the proportion reported by us.[10] But Biswas et al. have also reported on a total impairment prevalence than this study.[10]

In the present study, moderate impairment was higher in males (6.81%) in comparison to females (3.96%), while on the other hand, severe impairment was more in females as compared to males (3.53% vs. 1.57%). It could be partially explained due to a higher proportion of widower females in the study population who had no support in ADLs due to death of their spouses. A study conducted in the urban district of Delhi[11] showed that ADL-impaired woman outnumber men in considerable proportion while in contrast Konjengbam et al. reported that males were more disabled than females.[6] In addition to the true geographical variation that may exist in the proportion of functional impairment among elderly, use of different scales to assess the functional status of elderly by different workers could also be the reason for the discrepancy between the results of different authors.

Conclusion

The bottom line of the review on functional disability is that the numbers are significant and are only going to rise. Therefore, policies focusing on improvement in geriatric health are required.